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Documentation Requirements

MedStar Visiting Nurse Association’s goal is to make the documentation process easier. Please, see the examples below to ensure your documentation is accurate and complete.

All documentation must include:

  • The patient's name
  • Date of encounter
  • Explanation of clinical findings during encounter
  • How clinical findings support homebound
  • How clinical findings show need for skilled care
  • Signed and dated by the certifying physician

Examples of documentation denied by Medicare:

  • Diagnoses/clinical findings on Face-to-Face not related to home care ordered
  • Altered documentation without acceptable notations for changes
  • Face-to-Face signed by non-physician practitioner
  • No date of Face-to-Face encounter
  • Not clearly titled as Face-to-Face encounter
  • Face-to-Face completed by employee or representative of the home care agency

Download our Face-to-Face Encounter and Homecare Certification Form

Contact Us

To find out more about our home healthcare services, call: 800-862-2166.